How Is Rheumatoid Arthritis Treated?

Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: to relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person's sense of well-being and ability to function.

Good communication between the patient and doctor is necessary for effective treatment. Talking to the doctor can help ensure that exercise and pain management programs are provided as needed, and that drugs are prescribed appropriately. Talking to the doctor can also help people who are making decisions about surgery.

Goals of Treatment

Relieve pain

Reduce inflammation

Slow down or stop joint damage

Improve a person's sense of well-being and ability to function

Current Treatment Approaches

Lifestyle

Medications

Surgery

Routine monitoring and ongoing care

Health behavior changes: Certain activities can help improve a
person's ability to function independently and maintain a positive outlook.

Rest and exercise: People with rheumatoid arthritis need a good
balance between rest and exercise, with more rest when the disease is active
and more exercise when it is not. Rest helps to reduce active joint
inflammation and pain and to fight fatigue. The length of time for rest will
vary from person to person, but in general, shorter rest breaks every now
and then are more helpful than long times spent in bed.

Exercise is important for maintaining healthy and strong muscles,
preserving joint mobility, and maintaining flexibility. Exercise can also
help people sleep well, reduce pain, maintain a positive attitude, and lose
weight. Exercise programs should take into account the person's physical
abilities, limitations, and changing needs.

Joint care: Some people find using a splint for a short time
around a painful joint reduces pain and swelling by supporting the joint and
letting it rest. Splints are used mostly on wrists and hands, but also on
ankles and feet. A doctor or a physical or occupational therapist can help a
person choose a splint and make sure it fits properly. Other ways to reduce
stress on joints include self-help devices (for example, zipper pullers,
long-handled shoe horns); devices to help with getting on and off chairs,
toilet seats, and beds; and changes in the ways that a person carries out
daily activities.

Stress reduction: People with rheumatoid arthritis face emotional
challenges as well as physical ones. The emotions they feel because of the
disease -- fear, anger, and frustration -- combined with any pain and physical
limitations can increase their stress level. Although there is no evidence
that stress plays a role in causing rheumatoid arthritis, it can make living
with the disease difficult at times. Stress also may affect the amount of
pain a person feels. There are a number of successful techniques for coping
with stress. Regular rest periods can help, as can relaxation, distraction,
or visualization exercises. Exercise programs, participation in support
groups, and good communication with the health care team are other ways to
reduce stress.

Healthful diet: With the exception of several specific types of
oils, there is no scientific evidence that any specific food or nutrient
helps or harms people with rheumatoid arthritis. However, an overall
nutritious diet with enough -- but not an excess of -- calories, protein, and
calcium is important. Some people may need to be careful about drinking
alcoholic beverages because of the medications they take for rheumatoid
arthritis. Those taking methotrexate may need to avoid alcohol altogether
because one of the most serious long-term side effects of methotrexate is
liver damage.

Climate: Some people notice that their arthritis gets worse when
there is a sudden change in the weather. However, there is no evidence that
a specific climate can prevent or reduce the effects of rheumatoid
arthritis. Moving to a new place with a different climate usually does not
make a long-term difference in a person's rheumatoid arthritis.

Medications: Most people who have rheumatoid arthritis take
medications. Some medications (analgesics) are used only for pain relief; others
[corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs)] are used to
reduce inflammation. Still others, often called disease-modifying antirheumatic
drugs (DMARDs), are used to try to slow the course of the disease. The newest
and perhaps most promising class of arthritis medications are the biologic
response modifiers. These are genetically engineered medications that help
reduce inflammation and structural damage to the joints by interrupting the
cascade of events that drive inflammation. Currently, seven biologic response
modifiers are approved for rheumatoid arthritis. They work in one of several
ways:

Anakinra
(Kineret), works by blocking a cytokine called interleukin-1 (IL-1) that
is seen in excess in patients with rheumatoid arthritis.

Rituximab (Rituxan)
stops the activation of a type of white blood cell called B cells. This
reduces the overall activity of the immune system, which is overactive
in people with rheumatoid arthritis.

Abatacept (Orencia) blocks a
particular chemical that triggers the overproduction of white blood
cells called T cells that play a role in rheumatoid arthritis
inflammation.

2Brand names included in this booklet are provided as examples only, and
their inclusion does not mean that these products are endorsed by the
National Institutes of Health or any other Government agency. Also, if a
particular brand name is not mentioned, this does not mean or imply that the
product is unsatisfactory.

For many years, doctors initially prescribed aspirin or other
pain-relieving drugs for rheumatoid arthritis, and waited to prescribe more
powerful drugs only if the disease worsened. In recent decades this approach
to treatment has changed as studies have shown that early treatment with
more powerful drugs -- and the use of drug combinations instead of one
medication alone -- may be more effective in reducing or preventing joint
damage. Someone with persistent rheumatoid arthritis symptoms should see a
doctor familiar with the disease and its treatment to reduce the risk of
damage.

The person's general condition, the current and predicted severity of the
illness, the length of time he or she will take the drug, and the drug's
effectiveness and potential side effects are important considerations in
prescribing drugs for rheumatoid arthritis. The table below shows currently
used rheumatoid arthritis medications, along with their uses and effects,
side effects, and monitoring requirements.

Many of the new drugs that help reduce disease in rheumatoid arthritis do
so by reducing the inflammation that can cause pain and joint damage.
However, in some instances, inflammation is one mechanism the body normally
uses to maintain health, such as to fight infection and possibly to stop
tumors from growing. The magnitude of the risk from the treatment is hard to
judge because infections and cancer can occur in patients with rheumatoid
arthritis who are not on treatment, and probably more commonly than in
healthy individuals. Nevertheless, appropriate caution and vigilance are
justified.

Surgery:Several types of surgery are available to patients
with severe joint damage. The primary purpose of these procedures is to reduce
pain, improve the affected joint's function, and improve the patient's ability
to perform daily activities. Surgery is not for everyone, however, and the
decision should be made only after careful consideration by the patient and
doctor. Together they should discuss the patient's overall health, the condition
of the joint or tendon that will be operated on, and the reason for, as well as
the risks and benefits of, the surgical procedure. Cost may be another factor.

Following are some of the more common surgeries performed for rheumatoid
arthritis:

Joint replacement: Joint replacement involves removing all or part of
a damaged joint and replacing it with synthetic components. Joint
replacement is available for a number of different joints, but the most
commonly replaced joints are the hips and knees. Joint replacement surgery
is done primarily to relieve pain and improve or preserve function.

Although joint replacement traditionally involved a large incision and
long recovery, new minimally invasive surgeries are making it possible to do
some forms of joint replacement with smaller incisions and a shorter, easier
recovery.

Artificial joints are not always permanent and may eventually have to be
replaced. This may be an important consideration for young people.

Arthrodesis (fusion): Arthrodesis is a surgical procedure that
involves removing the joint and fusing the bones into one immobile unit,
often using bone grafts from the person's own pelvis. Although the procedure
limits movement, it can be useful for increasing stability and relieving
pain in affected joints. The most commonly fused joints are the ankles and
wrists and joints of the fingers and toes.

Tendon reconstruction: Rheumatoid arthritis can damage and even
rupture tendons, the tissues that attach muscle to bone. This surgery, which
is used most frequently on the hands, reconstructs the damaged tendon by
attaching an intact tendon to it. This procedure can help to restore hand
function, especially if the tendon is completely ruptured.

Synovectomy: In this surgery, the doctor actually removes the
inflamed synovial tissue. Synovectomy by itself is seldom performed now
because not all of the tissue can be removed, and it eventually grows back.
Synovectomy is done as part of reconstructive surgery, especially tendon
reconstruction.

Routine Monitoring and Ongoing Care:Regular medical care is
important to monitor the course of the disease, determine the effectiveness and
any negative effects of medications, and change therapies as needed.

Monitoring typically includes regular visits to the doctor. It also may
include blood, urine, and other laboratory tests and x rays.

People with rheumatoid arthritis may want to discuss preventing
osteoporosis with their doctors as part of their long-term, ongoing care.
Osteoporosis is a condition in which bones become weakened and fragile.
Having rheumatoid arthritis increases the risk of developing osteoporosis
for both men and women, particularly if a person takes corticosteroids. Such
patients may want to discuss with their doctors the potential benefits of
calcium and vitamin D supplements or other treatments for osteoporosis.

Alternative and Complementary Therapies: Special diets, vitamin
supplements, and other alternative approaches have been suggested for treating
rheumatoid arthritis.

Research shows that some of these, for example, fish oil supplements, may
help reduce arthritis inflammation. For most, however, controlled scientific
studies either have not been conducted on them or have found no definite benefit
to these therapies.

As with any therapy, patients should discuss the benefits and drawbacks with
their doctors before beginning an alternative or new type of therapy. If the
doctor feels the approach has value and will not be harmful, it can be
incorporated into a patient's treatment plan. However, it is important not to
neglect regular health care. The Arthritis Foundation publishes material on
alternative therapies as well as established therapies, and patients may want to
contact this organization for information.

Medications

Uses/Effects

Side Effects

Monitoring

Analgesics and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Analgesics relieve pain; NSAIDs are a large class of medications useful against pain and inflammation. A number of NSAIDs are available over the counter. More than a dozen others-including a subclass called COX-2 inhibitors-are available only with a prescription.

NSAIDs can cause stomach irritation or, less often, can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because they alter the way the body uses or eliminates these other drugs. NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.

Check with your health care provider or pharmacist before you take NSAIDs. Before taking traditional NSAIDs, let your provider know if you drink alcohol or use blood thinners or if you have any of the following: sensitivity or allergy to aspirin or similar drugs, kidney or liver disease, heart disease, high blood pressure, asthma, or peptic ulcers.

NSAIDs help relieve pain within hours of admin-istration in dosages
available over-the-counter
(available for all three medications). They relieve pain and inflammation
in dosages available in prescription form
(ibu-profen and ketoprofen). It may take several days to reduce
inflammation.

For all traditional NSAIDs: Before taking these drugs, let your
doctor know if you drink alcohol or use blood thinners or if you have or
have had any of the following: sensitivity or allergy to aspirin or
similar drugs, kidney or liver disease, heart disease, high blood
pressure, asthma, or peptic ulcers.

Corticosteroids

These are steroids given by mouth or injection. They are used to
relieve inflammation and reduce swelling, redness, itching, and allergic
reactions

These steroids are available in pill
form or as an injection into a
joint. Improvements are seen in several hours up to 24 hours after
administration. There is potential for serious side effects, especially
at high doses. They are used for severe flares and when the disease does
not respond to NSAIDs and DMARDs.

Doctor monitoring for continued effectiveness of medication and for
side effects is needed.

Disease-modifying antirheumatic drugs (DMARDs)

These are common arthritis medications. They relieve painful,
swollen joints and slow joint damage, and several DMARDs may be used
over the disease course. They take a few weeks or months to have an
effect, and may produce significant improvements for many patients.
Exactly how they work is still unknown

Side effects vary with each medicine.
DMARDs may increase risk of infection, hair loss, and kidney or liver damage.

Doctor monitoring allows the risk of toxicities to be weighed
against the potential benefits of individual medications.

Before taking this drug, tell your doctor if you
use allopurinol or have kidney or liver disease. This drug can reduce your
ability to fight infection, so call your doctor immediately if you develop
chills, fever, or a cough. Regular blood and liver function tests are
needed.

Cyclosporine

This medication was first used in organ transplantation to prevent
rejection. It is used in patients who have not responded to other drugs.

Before taking this drug, tell your
doctor if you have one of the following: sensitivity to castor oil (if
receiving the drug by injection), liver or kidney disease, active
infection, or high blood pressure. Using this drug may make you more
susceptible to infection and certain cancers. Do not take live vaccines
while on this drug.

Redness or soreness of tongue; swelling
or bleeding gums; skin rash or itching; ulcers or sores on lips, mouth, or
throat;
irritation on tongue. Joint pain may occur for one or two days after
injection.

Before taking this drug, tell your
doctor if you have any of the following: lupus, skin rash, kidney disease,
or colitis.
Periodic urine and blood tests are needed to check for side effects.

Before taking this medication, let your
doctor know if you have one of the following: active infection, liver
disease, known immune deficiency, renal insufficiency, or underlying
malignancy. You will need regular blood tests, including liver function
tests. Leflunomide must not be taken during pregnancy because it may
cause birth defects in humans.

Methotrexate

This drug can be taken by mouth or by injection and
results in rapid improvement (it usually takes 3-6 weeks to begin
working). It appears to be very effective, especially in combination
with infliximab or etanercept. In general, it produces more favorable
long-term responses compared with other DMARDs such as sulfasalazine,
gold sodium thiomalate, and hydroxychloroquine.

Doctor monitoring is important, particularly if you
have an abnormalblood count, liver or lung disease, alcoholism,
immune-system deficiency, or active infection. Methotrexate must not be
taken during pregnancy because it may cause birth defects in humans.

Sulfasalazine

This drug works to reduce the signs and symptoms of
rheumatoid arthritis by suppressing the immune system.

These medications are highly effective for treating
patients with an inadequate response to DMARDs. They may be prescribed
in combination with some DMARDs, particularly methotrexate.
Etanercept requires subcutaneous (beneath the skin) injections two
times per week. Infliximab is taken intravenously (IV) during a
2-hour procedure. It is administered with methotrexate. Adalimumab
requires injections every 2 weeks. Long-term efficacy and safety are
uncertain.

Long-term efficacy and safety are uncertain. Doctor
monitoring is important, particularly if you have an active infection,
exposure to tuberculosis, or a central nervous system disorder.
Evaluation for tuberculosis is necessary before treatment begins.

Redness, swelling, bruising, or pain at the site of
injection; head-ache; upset stomach; diarrhea; runny nose; and stomach
pain.

Doctor monitoring is required.

*NOTE: Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.